On the Radar
Issue 189
1 September 2014
On the Radar is a summary of some of the recent publications in the areas of safety and quality in
health care. Inclusion in this document is not an endorsement or recommendation of any publication
or provider.
Access to particular documents may depend on whether they are Open Access or not, and/or your
individual or institutional access to subscription sites/services. Material that may require
subscription is included as it is considered relevant.
On the Radar is available online, via email or as a PDF document from
http://www.safetyandquality.gov.au/publications-resources/on-the-radar/
If you would like to receive On the Radar via email, you can subscribe on our website
http://www.safetyandquality.gov.au/ or by emailing us at mail@safetyandquality.gov.au .
You can also send feedback and comments to mail@safetyandquality.gov.au .
HU
HU
U
U
For information about the Commission and its programs and publications, please visit
http://www.safetyandquality.gov.au
You can also follow us on Twitter @ACSQHC.
On the Radar
Editor: Dr Niall Johnson niall.johnson@safetyandquality.gov.au
Contributors: Niall Johnson
Reports
National Statement on Health Literacy
Sydney, Australian Commission on Safety and Quality in Health Care, 2014.
URL
http://www.safetyandquality.gov.au/publications/health-literacy-national-statement/
The Australian Commission on Safety and Quality in Health Care has released the
National Statement on Health Literacy.
Almost 60% of Australians have a low level of individual health literacy. This is
important to the safety, quality and effectiveness of health care. Low levels of
individual health literacy contribute to poorer health outcomes, increased risk of an
adverse event and higher healthcare costs. People with low levels of health literacy
Notes
may not understand their medication instructions, be able to interpret nutrition
labels on food, or be able to understand the risks associated with different treatment
options enough to make an informed choice.
The Commission has been working with healthcare professionals, consumers,
policy makers and researchers to explore the role that health literacy plays in safe
and high-quality care and to develop a national approach as a basis for coordinated
and collaborative action.
On the Radar Issue 189
1
The National Statement on Health Literacy proposes a coordinated approach to
health literacy based on:
 embedding health literacy into systems
 ensuring effective communication
 integrating health literacy into education.
This has now been endorsed by Australian, state and territory Health Ministers as
the national approach to health literacy.
Optimizing Scopes of Practice: New Models for a New Health Care System
Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, et al.
Ottawa, Ontario: Canadian Academy of Health Sciences; 2014.
http://www.cahs-acss.ca/optimizing-scopes-of-practice-new-models-of-care-for-aURL
new-health-care-system/
The Canadian Academy of Health Sciences has published this report examining the
question of ‘What are the scopes of practice that will be most effective to support
innovative models of care for a transformed health care system to serve all
Canadians?’
During the course of the work it emerged that “optimizing scopes of practice,
paired with evolving models of shared care can provide a multidimensional
Notes
approach to shift the health care system from one that is characteristically siloed
to one that is collaborative and patient-focused.” Key aspects for this vision are:
“flexibility– empowering the collaborative practice team to determine the relative
responsibilities of the different practitioners based upon community need.
accountability– ensuring the optimization of scopes of practice through an
accreditation process within a professional regulatory environment.”
Journal articles
Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a
National Database, 2010–2012
Donaldson LJ, Panesar SS, Darzi A
PLoS Med. 2014;11(6):e1001667.
DOI
http://dx.doi.org/10.1371/journal.pmed.1001667
This paper reports on an analysis of deaths in English hospitals that had patient
safety implications. The (adult) deaths were recorded in the UK National Health
Service and covered 2,010 incidents involving patients aged 16 and over in acute
hospital settings. The deaths were reported after mandatory reporting of such
incidents was introduced.
The aim of the study was to classify reports of deaths due to unsafe care into broad
areas of systemic failure capable of being addressed by stronger policies,
procedures, and practices.
Notes
The types of incident were aggregated into six areas of apparent systemic failure:
mismanagement of deterioration (35%), failure of prevention (26%), deficient
checking and oversight (11%), dysfunctional patient flow (10%), equipmentrelated errors (6%), and other (12%).
The most common incident types were failure to act on or recognise deterioration
(23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected
per-operative death (6%), and poor or inadequate handover (5%).
This list is not in itself particularly surprising and in many of these areas there are
known interventions and methods for addressing these types of incident.
2
On the Radar Issue 189
Medical service redesign shares the load saving 6000 bed days and improving morale
Toomath R, Szecket N, Nahill A, Denison T, Spriggs D, Lay C, et al.
Internal Medicine Journal. 2014 Aug;44(8):785-90.
DOI
http://dx.doi.org/10.1111/imj.12477
This paper reports on how a New Zealand hospital split its staff into teams to deal
with patients expected to have short stays and those expected to have longer stays.
The authors report that in the 18 months from “the introduction of the new model,
the average length of stay has fallen from 3.7 to 3.2 days (14%) and the median
length of stay by 28%, resulting in a saving of 6000 bed days per year.” However,
they also note that readmission, inpatient and 30-day mortality rates were
Notes
unchanged.
The authors identify the following factor for the success of the intervention:
management support; iterative engagement of a range of staff; provision of
timely data analysis; increases in senior medical officer staffing and
reorganisation leading to more predictable and fair work practices.
They also identify that discontinuity (whether between doctors and patients or
within the medical team.) is a challenge.
The influence of organizational factors on patient safety: Examining successful handoffs in health
care
Richter JP, McAlearney AS, Pennell ML
Health Care Manage Rev. 2014 [epub].
DOI
http://dx.doi.org/10.1097/HMR.0000000000000033
This study sought to examine how perceptions of organisational factors influencing
patient safety are associated with perceptions of successful patient
handovers/handoffs and which factors have the greatest influence and whether
perceptions of these factors differ for management and clinical staff. The study
used survey responses from 515,637 respondents at 1,052 hospitals in (US)
Hospital Survey on Patient Safety Culture.
The authors report that “perceived teamwork across units was the most significant
Notes
predictor of perceived successful handoffs. Perceptions of staffing and
management support for safety were also significantly associated with perceived
successful handoffs for both management and clinical staff. For management
respondents, perceptions of organizational learning or continuous improvement
had a significant positive association with perceived successful handoffs, whereas
the association was negative for clinical staff. Perceived communication openness
had a significant association only among clinical staff.”
For information on the Commission’s work on clinical communications, including clinical
handover, see http://www.safetyandquality.gov.au/our-work/clinical-communications/
Racial and Ethnic Disparities in Patient Safety
Okoroh JS, Uribe EF, Weingart S
Journal of Patient Safety.2014 [epub]
http://dx.doi.org/10.1097/PTS.0000000000000133
DOI /
http://pdfs.journals.lww.com/journalpatientsafety/9000/00000/Racial_and_Ethnic_
URL
Disparities_in_Patient_Safety_.99726.pdf
This American study examined the literature (1991 to 1 May 2013) for studies on
Notes
racial and ethnic disparities in patient safety.
On the Radar Issue 189
3
The study sought to explore differences in reporting race/ethnicity in studies on
disparities in patient safety; assess adjustment for socioeconomic status,
comorbidity, and disease severity; and make recommendations on the inclusion of
race/ethnicity for future studies on adverse events.
They report relatively few studies, with 24 being fully reviewed and that what
evidence there was on the existence of disparities in adverse events was mixed.
They noted that “Poor stratification of outcomes by race/ethnicity and
consideration of geographic and hospital-level variations explain the inconclusive
evidence. “
American Journal of Medical Quality
September 2014; 29 (5)
URL
http://ajm.sagepub.com/content/29/5?etoc
A new issue of the American Journal of Medical Quality has been published.
Articles in this issue of the American Journal of Medical Quality include:
 Identifying Hospital-Wide Harm: A Set of ICD-9-CM-Coded Conditions
Associated With Increased Cost, Length of Stay, and Risk of Mortality
(Richard A Bankowitz, Barbara Doyle, M Duan, E Kroch, and J Martin)
 Using NSQIP to Investigate SCIP Deficiencies in Surgical Patients With a
High Risk of Developing Hospital-Associated Urinary Tract Infections
(Amber W Trickey, Moira E Crosby, Fran Vasaly, Jean Donovan, John
Moynihan, and H David Reines)
 A Multifaceted Initiative to Improve Clinician Awareness of Pain
Management Disparities (Stephen J Bekanich, Nathan Wanner, Scott
Junkins, K Mahoney, K A Kahn, C A Berry, S A Stowell, and A J Gardner)
 An Evaluation of Ventilator-Associated Pneumonia Process Measure
Sampling Strategies in a Surgical ICU (Nishi Rawat, Ting Yang, Kathleen
Speck, Jennifer Helzer, Cathleen Barenski, and Sean Berenholtz)
 Health Care Quality Improvement Publication Trends (Gordon H Sun,
Mark P MacEachern, R J Perla, J M Gaines, M M Davis, and W H Shrank)
 A Survey of Handoff Practices in Emergency Medicine (Chad Kessler,
Notes
Faizan Shakeel, H G Hern, J S Jones, J Comes, C Kulstad, F A Gallahue, B
D Burns, B J Knapp, M Gang, M Davenport, B Osborne, and L I Velez)
 Patient-Reported Missed Nursing Care Correlated With Adverse
Events (Beatrice J. Kalisch, Boqin Xie, and Beverly Waller Dabney)
 Medical ICU Admissions During Weekday Rounds Are Not Associated
With Mortality: A Single-Center Analysis (Heath E Latham, Aaron Pinion,
Luis Chug, S K Rigler, A R Brown, J D Mahnken, and A O’Brien-Ladner)
 Primary Care Units in Emilia-Romagna, Italy: An Assessment of
Organizational Culture (Valerie P Pracilio, Scott W Keith, John McAna,
Giuseppina Rossi, Ettore Brianti, Massimo Fabi, and Vittorio Maio)
 Use of Data Envelopment Analysis to Quantify Opportunities for
Antibacterial Targets for Reduction of Health Care–Associated Clostridium
difficile Infection (Amy L Pakyz and Yasar A Ozcan)
 The Development of a Validated Checklist for Femoral Venous
Catheterization: Preliminary Results (Lee Ann Riesenberg, Katherine
Berg, Dale Berg, Joshua Davis, A Schaeffer, E M Justice, and G Tinkoff)
 Motivating Physicians to Improve Quality: Light the Intrinsic Fire (Kurt
R Herzer and Peter J Pronovost)
4
On the Radar Issue 189



Much Work Still to Be Done to Prevent Central Line–Associated
Bloodstream Infections (Kevin T Kavanagh, Lindsay E Calderon, and
Daniel M Saman)
The Multiple Benefits of Inserting Interdisciplinary Quality
Improvement Teams Led by Medical Students Into a Faculty Practice
Primary Care Clinic (Aniesa D Slack, Megan A Dingwall, Jeffrey C Stone,
Melissa Gaines, and Robert G Badgett)
Inpatient Glycemic Control in the Chinese Population: Preliminary Data
From an Academic Teaching Hospital (Shi-Dou Lin, Maw-Soan Soon,
Shih-Te Tu, Hui-Fang Hsiao, Jung-Min Chen, Ke-Hong Lin, Mei-Jung Lin,
Jeng-Fu Kuo, Ya-Leng Jhang, and Ming-Chia Hsieh)
BMJ Quality and Safety online first articles
URL
http://qualitysafety.bmj.com/content/early/recent
BMJ Quality and Safety has published a number of ‘online first’ articles, including:
 A systematic review of behavioural marker systems in healthcare: what
do we know about their attributes, validity and application? (Aaron S Dietz,
Peter J Pronovost, Kari N Benson, Pedro Alejandro Mendez-Tellez, Cynthia
Notes
Dwyer, Rhonda Wyskiel, Michael A Rosen)
 Cost and turn-around time display decreases inpatient ordering of
reference laboratory tests: a time series (Daniel Z Fang, Gurmeet Sran,
Daniel Gessner, Pooja D Loftus, Ann Folkins, J Y Christopher III, L Shieh)
Online resources
[UK] NICE Evidence Updates
https://www.evidence.nhs.uk/about-evidence-services/bulletins-and-alerts/evidence-updates
The UK’s National Institute for Health and Care Excellence (NICE) has published an update on
their Evidence Updates site. The new update is on ‘acute upper gastrointestinal bleeding’.
The new Evidence Updates focus on a summary of selected new evidence relevant to NICE clinical
guideline 141 ‘Acute upper gastrointestinal bleeding: management’ (2012).
An Evidence Update Advisory Group, comprised of topic experts, reviewed the prioritised evidence
and provided a commentary.
[USA] Improving Global Health: Focusing on Quality and Safety
https://www.edx.org/course/harvardx/harvardx-ph555x-improving-global-health-1679
Improving Global Health: Focusing on Quality and Safety is an eight-week massive open online
course (MOOC) presented by HarvardX. Ashish Jha, MD, a Professor of Health Policy at the
Harvard School of Public Health, will lead the free online course, which starts on 16 September.
The course covers issues including:
 The importance of focusing on quality for improving population health
 A framework for understanding healthcare quality
 Approaches to quality measurement
 The role of information and communication technology in quality improvement
 Tools and contextual knowledge for quality improvement
On the Radar Issue 189
5
Disclaimer
On the Radar is an information resource of the Australian Commission on Safety and Quality in
Health Care. The Commission is not responsible for the content of, nor does it endorse, any articles
or sites listed. The Commission accepts no liability for the information or advice provided by these
external links. Links are provided on the basis that users make their own decisions about the
accuracy, currency and reliability of the information contained therein. Any opinions expressed are
not necessarily those of the Australian Commission on Safety and Quality in Health Care.
6
On the Radar Issue 189